Massive Duodenal Bleeding after the Migration of Endovascular Coils into the Small Bowel

Among gastrointestinal emergencies, acute upper gastrointestinal bleeding remains a challenging clinical problem owing to significant patient morbidity and costs involved in management. Endoscopic hemostatic therapy is the mainstay of treatment and decreases the incidence of re-bleeding, the need for surgery, morbidity, and mortality. However, in 8%–15% of patients with upper gastrointestinal bleeding, endoscopic hemostatic therapy does not successfully control bleeding. Trans-arterial coil embolization is an effective alternative treatment for endoscopic hemostatic failure; however, this procedure can induce adverse outcomes, such as non-target vessel occlusion, vessel dissection and perforation, and coil migration. Coil migration is rare but causes severe complications, such as re-bleeding and bowel ischemia. However, in most cases, coil migration is local and involves spontaneous healing without serious complications. Here, we report the case of a patient who underwent trans-arterial coil embolization of the gastroduodenal artery with the purpose of controlling massive duodenal bleeding, resulting in a fatal outcome caused by coil migration.

Medical rehabilitation system for patients in acute rehabilitation units

Acute-phase rehabilitation hospitals focus on managing disabilities, reducing sequelae and symptoms, and enhancing social reintegration, to provide patients with the highest possible independence and the best quality of life. In order to achieve these goals, it is necessary to ensure the appropriate length of hospital stays based on a consideration of disease severity and patients' potential for rehabilitation, as well as to provide multidisciplinary rehabilitation. Multidisciplinary rehabilitation has been shown to be effective in the management of complex or severe conditions. Hospitals should include rehabilitation centers (specialized rehabilitation units) for patients with complex or severe needs. Starting in acute settings, specialized rehabilitation wards provide intensive, highly specialized interventions to restore function to patients with complex rehabilitation needs. Financial resources should be allocated to rehabilitation services to implement recommendations for the delivery of medical services In Korea, the appropriate allocation of resources for rehabilitation could increase both the availability and the quality of rehabilitation services by facilitating the establishment of specialized rehabilitation units in acute settings.

Erratum: Biomechanical Parameters in Arch Building Gait Measured by Gait Analysis System with Pressure Sensor / 대한스포츠의학회지

The funding acknowledgment in this article was omitted as published.

Biomechanical Parameters in Arch Building Gait Measured by Gait Analysis System with Pressure Sensor / 대한스포츠의학회지

The objective of study was to compare biomechanical parameters between normal and arch building gait in healthy subjects. A total of 40 feet from 20 healthy adults were evaluated in this study. The participants were asked to walk on a treadmill comfortably at 2 km/hr for 30 seconds. Then, they were asked to walk after making arch building through raising arches with their feet by pulling the big toe toward the heel. Gait parameters such as geometry, center of pressure, maximum force, and maximum pressure were measured in normal and the arch building gait using a gait analysis system equipped with pressure sensor. Arch building gait demonstrated significantly (p0.05) different between the two conditions. Geometry, phase, and time parameters were not significantly (p>0.05) different between the two conditions, either. Although forefoot and midfoot maximum force were significantly decreased in arch building gait compared to those in normal gait, the maximum pressure of forefoot was not significantly changed, indicating decreased area of forefoot contact during arch building gait. The arch building gait moves the center of presser to the hind foot and redistributes the contact area, thus changing the distribution of maximum pressure.

Page kidney after botulinum toxin injection during chiropractic care / 영남의대학술지

Page kidney refers to the phenomenon of hypertension secondary to long-standing compression of renal parenchyma caused by renal subcapsular collection. The most common cause of renal subcapsular collection is a hematoma which usually occurs after a history of blunt trauma. A 42-year-old female patient who received botulinum toxin injection in her back during chiropractic care was admitted to the emergency room with sudden bilateral flank pain and hypertension. The computed tomography (CT) images demonstrated the presence of bilateral subcapsular renal hematoma. The patient was treated conservatively and recovered well. The follow up CT images showed markedly resolved bilateral hematoma.

Idiopathic hypereosinophilic syndrome presenting with urinary frequency, abdominal pain, and diarrhea

Idiopathic hypereosinophilic syndrome (IHES) is a rare disorder defined by persistent blood eosinophilia, evidence of eosinophil-associated organ dysfunction and absence of secondary causes. Eosinophilic infiltration and its mediator release can cause damage to multiple organs. Although IHES can involve every organ system, bladder involvement is rarely evidenced. We recently reported a case of IHES with both bladder and gastrointestinal tract involvement. A 43-year-old woman visited Hallym University Sacred Heart Hospital complaining of urinary frequency, abdominal pain, and diarrhea for several months. Abdominal pelvic computed tomographic scan showed diffuse wall thickenings in her bladder and colon with small pelvic ascites. Laboratory investigation showed a marked peripheral eosinophilia and tissue biopsies confirmed eosinophilic infiltration in the bladder wall, esophagus, and duodenum. The patient was treated with prednisolone and her eosinophilia and symptoms have gradually improved.

A Case of Hepatitis B Virus Reactivation in a HBsAg-Negative and Anti-HBs-Positive Patient with Diffuse Large B-Cell Lymphoma after Rituximab plus CHOP Chemotherapy

The reactivation of hepatitis B virus (HBV) is well known complication among lymphoma patient related with chemotherapy. Rituximab is monoclonal antibody that targets B-lymphocytes for treatment of lymphoma and it increases reactivation of HBV. Although most of reactivation occurs in HBV carrier, it can also rarely occur when hepatitis B surface antigen (HBsAg) is negative. Furthermore it is less frequently reported in lymphoma patient when HBV serology shows HBsAg is negative and anti-HBs is positive. We report a case of HBV reactivation following 6 cycle of rituximab plus CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone) chemotherapy for diffuse large B-cell lymphoma in HBsAg negative/anti-HBs positive 58-year-old male, with a review of the literature.

A Case of Hyponatraemic Seizure Following Terlipressin Therapy for a Variceal Hemorrhage in a Patient with Liver Cirrhosis / 대한내과학회지

Terlipressin has splanchnic vasoconstrictive effects, and is generally used for the management of gastroesophageal variceal bleeding secondary to liver cirrhosis. Terlipressin is a synthetic arginine vasopressin (AVP) analog containing a nonapeptide sequence. Terlipressin has increased selectivity for the V1 receptor, compared with AVP; hence, it is considered to be a safe vasoconstrictor. However, side effects such as hyponatremia and seizure, although very rare, have been reported. Hyponatremia related to terlipressin may be caused by the syndrome of inappropriate antidiuresis (SIAD), which is a disorder of sodium and water balance characterized by hypotonic hyponatremia without elevation of the antidiuretic hormone level. Here, we report a case of hyponatremic seizure induced by an infusion of terlipressin in a 52-year-old female who had isolated gastric variceal bleeding secondary to alcoholic liver cirrhosis.

Balance Control and Knee Osteoarthritis Severity

OBJECTIVE: To investigate balance control according to the severity of knee osteoarthritis (OA) using clinical tests and Tetra-ataxiometric posturography (Tetrax(R)). METHOD: A total 80 patients with primary knee OA classified according to American College of Rheumatology criteria, and 40 age-matched controls were enrolled in this study. Of those with OA, 39 patients had mild OA (Kellgren-Lawrence [KL] grade 1, 2) and the other 41 had moderate to severe OA (KL grade 3, 4). The postural control capabilities of the subjects were assessed using the timed up and go test (TUG), Berg balance scale (BBS), and Tetrax(R), which utilizes two paired force plates to measure vertical pressure fluctuations over both heels and forefeet. The subjects were checked for their stability index (ST), Fourier index, weight distribution index (WDI), and synchronization index (SI) in eight positions using Tetrax(R). RESULTS: Patients with moderate to severe OA exhibited significantly higher stability indices in all positions than patients with mild OA. The Fourier index was also higher in patients with moderate to severe OA than in patients with mild OA. However, the weight distribution index and synchronization of both heels and forefeet were not significantly different in the three groups. CONCLUSION: These findings suggest that patients with moderate to severe OA have more deficits in balance control than those with mild disease. Therefore, evaluation of balance control and education aimed at preventing falls would be useful to patients with knee OA.

Atypical Supernumerary Phantom Limb and Phantom Limb Pain in Two Patients with Pontine Hemorrhage

Phantom limbs are usually observed after amputation of extremities. In patients after a stroke, a similar but rarely occurring phenomenon consisting of the patient experiencing the presence of an additional limb has been described. This phenomenon, generally called supernumerary phantom limb (SPL), may be caused by lesions in the right or left cerebral hemisphere, but has been predominantly reported in patients who have had a right hemispheric stroke. We report two cases of atypical SPL and phantom limb pain (PLP) after pontine hemorrhage. The patients were treated conservatively and their symptoms lasted more than 1 month. This is the first report of SPLs after left pontine hemorrhage, and phantom perception and pain lasted longer than those in previously observed cases. Our results indicate that SPL may be more common than reported; therefore, thorough examinations are essential for the care of stroke patients.

The Efficacy of Core Strengthening on the Trunk Balance in Patients with Subacute Stroke

OBJECTIVE: To investigate the efficacy of core strengthening on trunk balance in patients with subacute stroke. METHOD: Fifty-nine subacute hemiparetic stroke in-patients participated in this study. All patients were randomly assigned to one of two groups: the control group and the experimental group. Both groups received the same conventional physical therapies for 4 weeks. The experimental group received an additional core strengthening program (CSP). Korean mini-mental state examination (K-MMSE) and Korean Modified Barthel Index (K-MBI) were performed on admission. CSP was performed for 30 minutes a day, 3 days per week for 4 weeks. We selected nine exercises available for stroke patients, and divided them as three steps according to the degree of difficulty. Because of the muscle weakness in stroke patients, a physical therapist often helped them during exercise. Outcome measurement included trunk control test (TCT), trunk impairment scale (TIS), and Berg balance scale (BBS) and we compared both groups before and after the period of training. RESULTS: There were no significant differences in baseline general characteristics and initial values between the two groups. After rehabilitation therapy, both groups showed significant improvements in BBS, TIS, and TCT (p<0.05). Following 4 weeks of therapy, changes of BBS, TIS score in the experimental group were significantly higher than those of the control group (p<0.05). However, the change of TCT score was not significantly different. CONCLUSION: Analysis of different clinical parameters showed that better outcomes in BBS, TIS scores were achieved from CSP. This study suggests that CSP conducted for 4 weeks may be beneficial as a therapeutic technique for use in improvement of trunk balance in patients with subacute hemiparetic stroke.

The Correlation between the Cutaneous Silent Period and Ultrasonographic Findings of Median Nerve in Patients with Carpal Tunnel Syndrome

OBJECTIVE: To determine the relation between the latency and duration of the cutaneous silent period (CuSP) and ultrasonographic findings of patients with carpal tunnel syndrome (CTS). METHOD: Subjects included 50 hands of 33 patients with CTS with electrophysiologic evidence of CTS and 50 hands of 39 adults with no evidence of CTS. CuSP was measured on abductor pollicis brevis (APB) and adductor digiti minimi (ADM) by stimulation of digit 3. All subjects were examined with ultrasonography (US). Using US, the cross-sectional area (CSA) and flattening ratio (FR) of the median nerve were calculated under carpal tunnel. Analysis of differences between the control group and the CTS group was performed using ANOVA. RESULTS: Differences of CSA, FR, latency, and duration of CuSP in both APB, ADM muscles were observed between the two groups. Correlations were observed in the patient group in latency and duration of the APB muscle and only in duration of the ADM (p=0.048, r=0.159; p=0.035, r=-0.315; p=0.039, r=-0.293) muscle. Correlations were found only in duration of ADM (p=0.011, r=0.358) in the control group with respect to CSA. However, there was no correlation with FR. CONCLUSION: There seems to be a significant correlation between the CSA of the median nerve and the latency and duration of CuSP in patients with CTS. In addition, there seems to be a significant difference of CSA, FR, and latency in both APB and ADM between the two groups. CuSP and CSA might be useful for study that reflects intact small fibers in patients with CTS.

Prevalence of Asthma-like Symptoms in Subjects with Chronic Cervical Spinal Cord Injury

OBJECTIVE: To evaluate clinical relevance of airway hyperresponsiveness (AHR) in subjects with chronic spinal cord injury (SCI) by investigating the prevalence of asthma-like symptoms. METHOD: Two hundred twelve patients with SCI responded to the modified questionnaire of International Study of Asthma and Allergic disease in Children (ISSAC). Among them, 28 patients underwent a methacholine bronchial provocation test to measure AHR. RESULTS: The prevalence of AHR was significantly higher in subject with chronic cervical SCI compared with that in subjects with chronic thoracic or lumbar SCI (73.3% vs. 23.1%, p=0.023). In tetraplegics, the prevalence of wheezing during last 12 months, post-exercise wheezing, sleep disturbance due to nocturnal cough or wheezing, and dust-induced breathlessness were 40.0%, 37.8%, 33.3%, and 31.1% respectively, which were significantly higher than paraplegics and general population in Korea (p<0.05, p=0.001, 0.013, 0.002, 0.004 respectively). CONCLUSION: AHR in subjects with chronic cervical SCI might be a cause of symptomatic airway disturbances such as wheezing, cough, and breathlessness.

The Effects of the Local Steroid Injection in the Patients with Medial Superior Cluneal Nerve Entrapment

OBJECTIVE: The aim of this study was to evaluate the efficacy of the local steroid injection in the patients with medial superior cluneal nerve entrapment. METHOD: The participants were 20 (13 men, 7 women) patients with medial superior cluneal nerve entrapment diagnosed by Maigne's criteria (unilateral buttock pain, tender point at iliac crest, and relieved pain by nerve block). All patients were injected with 1% lidocaine 1.75 ml and triamcinolone 10 mg at maximal tender point which was 7~8 cm away from spinous process horizontally on the iliac crest. The visual analogue scale (VAS) and the modified Oswestry questionnaire (MOQ) were checked at before, 2 weeks and 4 weeks after injection. And the VAS was checked 10 min after injection to determine the accuracy of injections. RESULTS: The mean VAS scores of before injection, 10 min, 2 weeks, and 4 weeks after injection were 7.7, 2.8, 4.0, and 4.0 respectively. The mean MOQ of before injection, 2 weeks, 4 weeks after injection were 35.7, 23.8, and 23.8 respectively. Both VAS and MOQ were significantly different in before injection, 2 weeks and 4 weeks after injection (p<0.05). CONCLUSION: The local steroid injection is an effective treatment of medial superior cluneal nerve entrapment.

Effects of L4-5 Transforaminal Epidural Steroid Injection in L5 Radiculopathy

OBJECTIVE: The aim of this study was to compare the therapeutic and functional values between the L5-S1 transforaminal epidural steroid injection (TFESI) and L4-5 TFESI in patients with L5 radiculopathy. METHOD: Among 30 patients with unilateral herniated nucleus pulposus (HNP) and L5 radiculopathy, 15 patients received L5-S1 TFESI and 15 patients received L4-5 TFESI. All patients were checked visual analogue scale (VAS) and functional score before injection, after 1 day, 2 weeks and 4 weeks. RESULTS: The VAS of before injection, after 1 day, 2 weeks and 4 weeks were 6.6, 4.0, 3.0, and 2.8 in L5-S1 TFESI, 6.2, 3.9, 2.7, and 2.6 in L4-5 TFESI, respectively. The functional score of before injection, after 1 day, 2 weeks and 4 weeks were 1.8, 2.3, 2.6, and 3.0 in L5-S1 TFESI, 1.6, 2.2, 2.5, and 2.8 in L4-5 TFESI, respectively. There was no statistical difference between the groups (p>0.05). CONCLUSION: This study suggested that either L5-S1 TFESI or L4-5 TFESI could be a valuable treatment of L5 radicular pain.

The Effect of Intra-articular Hyaluronic Acid in Facet Syndrome of the Lumbar Spine

OBJECTIVE: To evaluate the efficacy of intra-articular hyaluronic acid injection and to compare this with the efficacy of steroid injection for the treatment of facet syndrome of the lumbar spine. METHOD: Sixty-eight patients with facet syndrome of the lumbar spine were assigned two groups at random to receive an intra-articular injection into the facet joint. One group received a intra-articular injection of the facet joint three times at 1 week apart with a mixture of hyaluronic acid 0.6~0.7 ml and 1% lidocaine 0.2 ml. The other group received a intra-articular injection of the facet joint one time with a mixture of triamcinolone 10 mg and 1% lidocaine 0.5~1 ml. The effectiveness of treatment was assessed with the visual analogue scale (VAS), and the patient's life activities were assessed with the modified Oswestry questionnaire. RESULTS: The VAS and the patient's life activity of the two groups all showed improvement at 1 week, 1 month and 3 months after injection, but there was no significant difference in the VAS scores and the patient's life activity scores between the two groups. CONCLUSION: The intra-articular injection of hyaluronic acid would be a good treatment method for facet syndrome of the lumbar spine.

Skin Lesion after Repeated Fluoroscopically Guided Procedures: A Case Report

The radiation exposure has multiple complication of various organs. Especially, the Food and Drug Administration has recently issued a bulletin warning of the risks of acute skin injury occurring during fluoroscopically guided procedures. Physicians need information about typical radiation doses during fluoroscopically guided various procedures and estimates of entrance skin dose must be monitored using thermoluminescent dosimetry, film badge dosimetry, pocket dosimetry and on-line computer system. Current National Council on Radiation Protection and Measurements recommended are that yearly total body dose should not exceed 50 mSv (5 rem) and that life time dose measured in millisieverts should not exceed one's age in years multiplied by 10. Types of skin injury are erythema, alopecia, dry desquamation, invasive fibrosis, dermal atropy, telangiectasia, moist desquamation, skin necrosis and secondary ulcer. Also, long-term exposure caused skin cancer. We experienced personally pigmentation on the finger nail and the hand after repeated fluoroscopically guided procedures. Thus, we report this case for giving warning to the physiatrist by the complications due to frequent exposure during procedures.